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Reasons to increase methadone dose

Background: Although methadone maintenance is an effective therapy for heroin dependence, some patients continue to use heroin and may benefit from therapeutic modifications.


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Nevertheless, many clinicians report that some patients can be stably maintained on lower methadone dosages to optimal effect, and clinic dosing practices vary substantially. Studies of individual responses to methadone treatment may be more easily translated into clinical practice. A volunteer sample of opioid-dependent US veterans initiating methadone treatment was prospectively observed over the year after treatment entry.

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Metrics details. Opioid maintenance treatment with methadone is regarded as gold standard in the therapy of opioid dependence. Sociodemographic and clinical data were gathered at baseline, and months 3, 6, and The frequency of adequate methadone doses ODAS increased Inadequacy of methadone dose was not associated with treatment failure RR 1. Addiction severity decreased statistically ificantly.

Methadone dose increase and abstinence reinforcement for treatment of continued heroin use during methadone maintenance

Compared to adequately dosed patients, inadequately dosed patients benefited more, in that they showed greater improvements in ODAS scores, had higher increases in methadone dose, and partially experienced more advanced sexual functioning. Application of ODAS was associated with improved methadone dose adequacy and addiction severity parameters as well as increased methadone doses.

Its usefulness should be corroborated in a controlled trial. Peer Review reports. Dependence on illegal opioids is a severe chronic illness, which is associated with relevant increased morbidity, functional impairments, social disintegration and premature mortality [ 1 — 3 ].

OMT reduces mortality, illicit drug use, frequency of injecting, HIV-transmission, and criminal activity whilst improving social integration [ 13 — 6 ]. Methadone and buprenorphine represent the medications most commonly used in OMT, and both have widely proven effectiveness. Methadone seems to have some advantages in terms of treatment retention when doses are in the range of 60— mg per day [ 78 ].

Aside from the absolute methadone dose, also the perception of dose inadequacy can lead to treatment non-adherence [ 9 ]. Consequently, an absolute methadone dose cannot serve as a sole indicator of sufficiency and should be related to clinical and patient reported parameters.

In this context, Trujols and colleagues suggested distinguishing between the concepts holding dosedose adequacysatisfaction with methadone as a medicationand satisfaction with treatment [ 10 ]. The latter two dimensions represent subjective phenomena, while the first two constructs include subjective and objective phenomena, with dose adequacy as a construct that can be measured by a validated instrument, the Opiate Dose Adequacy Scale ODAS [ 1112 ]. An adequate dose is defined as the amount of methadone, which allows the patient a to abstain from heroin use or only use heroin occasionally, b not to experience continuous opioid withdrawal or only mild withdrawal symptoms, c not to experience frequent episodes of heroin craving or only mild episodes, d in case of heroin use, to experience no or little effect of heroin cross-toleranceand e not to show s and symptoms of overmedication or only to a very small extent [ 10 ].

Scientific literature and scientifically based medical guidelines i.

Consequently, a relevant of German physicians deliver OMT with high abstinence orientation and lower substitution doses, despite the fact that stable abstinence is a rare outcome [ 16 ]. To examine dose adequacy in OMT in Germany, the present study was conducted. On average, patients with inadequate doses received higher doses Analyses of longitudinal data aimed to explore whether inadequate dosing le to treatment drop-out, how dose adequacy is associated with treatment outcome in general, and whether frequencies of inadequate dosing, addiction severity or sexual functioning changed over time.

We hypothesized, that inadequate dosing le to increased treatment drop-out, that addiction severity improves over time, and that sexual dysfunction is more pronounced in adequately dosed patients. Finally we wanted to explore, whether the use of ODAS could be associated with increased frequencies of adequate dosing.

DE study14 experienced substitution centres in Germany consecutively recruited patients with opioid dependence F Patients were excluded from study entry in case of inability to follow the study plan, decompensated mental disorders, non drug-related epileptic seizures and acute or severe somatic diseases.

Methadone dosing in opioid treatment programs: use the evidence

Over the one-year study period, visits were scheduled at baseline t 03 months t 16 months t 2and 12 months t 3. The baseline visit included a complete medical anamnesis and physical examination, as well as recording of routine laboratory testing if it was performed within 2 months prior the baseline visit. These diagnostic instruments were handed out by a nurse specialist.

Patients filled out the instruments in a secluded room during waiting time. The EuropASI is a validated and reliable instrument that covers drug use-related consequences in social, health and legal dimensions i. It was applied by trained interviewers, and reported scores reflect the interviewer severity ratings. The ODAS is a validated instrument to measure dose adequacy of methadone medication in maintenance treatment, which has been adapted to the German background [ 1112 ]. ODAS consists of six dimensions and comprises the areas heroin consumption, narcotic blockade, opiate withdrawal syndrome mental and somatic, craving for heroin, and methadone overdosing.

Induction to methadone treatment

Items have to be filled out either by the physician based on the patient anamnesis or by the patient himself. Scores range between 1 worst and 5 best. In this study, patients were regarded as not adequately dosed, if they reached a score of 3 or less in any ODAS dimension at any visit. On the other hand, patients were considered adequately dosed, if they reached a score of 4 or higher in every item in every visit. For comparative analyses two groups of patients were formed.

Doses were regarded as adequate, if scores of 4 or 5 were yielded in each item in every visit. Patients were ased to the inadequate dose group, if their ODAS score failed to meet adequate dosing threshold at least once throughout the study. The DISF-SR represents a validated and reliable item self-report instrument, which measures sexual functioning in five dimensions i. The study was approved by the ethics committee of the Physician Chamber Hamburg Reference PVGermany, and by all responsible physician chamber ethics committees outside the state of Hamburg.

The study was conducted in accordance with the declaration of Helsinki. Patients provided informed written consent and could withdraw from the study at any time without providing reasons and without negative consequences for further treatment.

Methadone dose increase and abstinence reinforcement for treatment of continued heroin use during methadone maintenance

Patients were included in the study between September and February Data analysis was performed with the SPSS 20 statistical package. Data is presented in a descriptive way, statistical analyses were performed to stratify by dose adequacy and in case of sexual functioning by gender.

The Mann—Whitney test, student t -test, or Chi 2 -test were used for analysis of statistical ificance. To determine the association of dose adequacy, age, and gender, relative risks were computed. Five hundred fifteen patients were enrolled in the study. Eleven patients withdrew their consent before the baseline visit. Two hundred thirty-two patients The remaining drop-outs were due to changed residence, entrance into drug free treatment, or unknown Fig. At baseline, patients were on average According to ODAS, In a similar direction, the average methadone dose for the whole group increased from Over time t 0 to t 3adequacy of methadone dosage increased statistically ificant in all ODAS domains, except methadone overdosing.

The average methadone dose in the adequate group at t 3 was Frequency of adequate methadone dose ODAS and average methadone dose by time t 0 : baseline, t 1 : 3 months, t 2 : 6 months, t 3 : 12 months. Changes in methadone dose and ODAS total score between baseline t 0 and 12 months t 3 by adequacy group.

Reasons for increasing daily methadone maintenance dosage among deceptive patients: a qualitative study

Inadequacy of methadone dosage according to ODAS was not associated with treatment failure; the relative risk for patients who were at least once inadequately dosed to fail in substitution treatment was 1. Additional tests explored the role of age and gender with regards to treatment failure. In this context, being younger than 40 years was associated with a higher risk for treatment failure RR 1.

Addiction severity according to EuropASI decreased during study participation, but differed by group. Disparities in addiction severity between the adequate and non-adequate group with statistically stronger problem load in all EuropASI domains in the inadequate group at baseline t 0resolved during study participation.

The subgroup analysis revealed no statistically ificant improvements in adequately dosed patients. This prospective cohort study examined retention, dose-adequacy, addiction severity, and sexual functioning within a months opioid maintenance treatment in more than patients in experienced German substitution centres.

OMT failed in Formulation of drugs, especially for long-term treatment, influences adherence and should be considered in OMT [ 22 ]. German retentions rates are at the upper end of the international span, which ranges between High retention rates in Germany may be regarded as an indicator for good quality delivery of OMT. Contrary, a surprisingly high of patients was inadequately dosed upon study entry. Abstinence orientation in German opioid substitution regulations may contribute to restrained dosing [ 162627 ].

The opiate dosage adequacy scale for identification of the right methadone dose—a prospective cohort study

However, inadequate methadone doses according to ODAS at baseline did not go along with premature treatment drop-out. This finding is not in line with corroborated study data [ 78 ]. Patients may have remained in OMT, because they were aware that their concerns were taken into.

Treatment effectiveness is also reflected by improvements in addiction severity, which was more pronounced in the group of inadequately dosed patients. Due to a more sufficient methadone dose, we expected stronger addiction severity improvements in adequately dosed patients.

However, more pronounced addiction severity in inadequately dosed patients at baseline together with more intense methadone dose adaptions may have contributed to stronger improvements of addiction severity in inadequately dosed patients [ 18 ]. This finding is relevant for clinical practice, as it shows, that inadequately dosed patients may derive relevant benefit from dose adaptations.

Increased adherence associated with adequate dosing might act as intermediary to improved functional outcomes [ 9 ]. It is noteworthy that, in inadequately dosed patients, work problems improved the most, followed by problems with psychoactive substances. This finding underlines the importance of OMT in social rehabilitation [ 3 ]. On the other hand, increased alcohol problems in inadequately dosed patients are of concern and call for an integrative addiction treatment approach, which takes the variety of substances consumed into.

Higher methadone doses have been associated with sexual dysfunction [ 28 ]. We did not find a positive association between methadone dose and sexual dysfunction. On the contrary, sexual function improved statistically although not ificantly during study participation with increasing methadone doses.